<?php 
	include_once '../common/header.php';
?>
<table width="1000" id="maintable" border="0" align="center" cellpadding="0" cellspacing="0">
<tr>
<td align="center">
<div id="popupContactAdminPage">
		<p id="contactArea">
			<form id="frmLogin" name="frmLogin" method="post">
			<table cellpadding="2px" cellspacing="1px" bgcolor="#95A2AD" width="660px" class="tableBorder">
			    <tr>
			        <td colspan="2" bgcolor="#302C3B">&nbsp;</td>
			    </tr>
			    <tr>
			    	<td align="center" width="100%" colspan="2">
			            <img src="images/register_button.png" border="0" align="absbottom" height="100" width="100" />
			        </td>
			        
			    </tr>
			    <tr>
			        <td align="center" width="25%">
			            <table>
			            	<tr height="150">
			            		<td align="right">
			            		<img src="images/personal_info.png" width="100" height="100" border="0" />
			            		</td>
			            	</tr>
			            	<tr height="130">
			            		<td align="right">
			            		<img src="images/account_information.png" width="100" height="100" border="0" />
			            		</td>
			            	</tr>
			            	<tr >
			            		<td align="right">
			            		<img src="images/communication_info.png" width="80" height="80" border="0" />
			            		</td>
			            	</tr>
			            </table>
			        </td>
			        <td width="75%">
			        	<div style="margin-left: 30px; width:430px">
			        	<!-- Personal Information Starts -->
			        	<fieldset>
			        		<legend>Personal Information</legend>
			        	<table>
			        		<tr>
			        			<td width="120">First Name <span style="color: #F00">*</span></td>
			        			<td>
			        				<input type="text" id="txtFirstName" name="txtFirstName" size="40" />
			        			</td>
			        		</tr>
			        		<tr>
			        			<td>Last Name</td>
			        			<td>
			        				<input type="text" id="txtLastName" name="txtLastName" size="40" />
			        			</td>
			        		</tr>
			        		<tr>
			        			<td>D.O.B<span style="color: #F00">*</span></td>
			        			<td valign="middle">
			        				<input type="text" id="txtDOB" name="txtDOB" size="36" />
			        				<img align="bottom" style="vertical-align: middle;" src="images/calendar.png" border="0" width="23" height="20" />
			        			</td>
			        		</tr>
			        		<tr>
			        			<td>Address</td>
			        			<td>
			        				<input type="text" id="txtAddress" name="txtAddress" size="40" />
			        			</td>
			        		</tr>
			        	</table>
			        	</fieldset>
			        	<!-- Personal Information Ends -->
			        	
			        	<div style="height: 10px;">&nbsp;</div>
			        	
			        	<!-- Account Information Starts -->
			        	<fieldset>
			        		<legend>Account Information</legend>
			        	<table>
			        		<tr>
			        			<td width="120">User Name<span style="color: #F00">*</span>:</td>
			        			<td>
			        				<input type="text" id="txtUserName" name="txtUserName" size="36" />&nbsp;
			        				<img align="bottom" style="vertical-align: middle;" src="images/check.png" border="0" width="23" height="20" />
			        			</td>
			        		</tr>
			        		<tr>
			        			<td>Password<span style="color: #F00">*</span>:</td>
			        			<td>
			        				<input type="password" id="txtPassword" name="txtPassword" size="40" />
			        			</td>
			        		</tr>
			        		<tr>
			        			<td>Retype Password<span style="color: #F00">*</span>:</td>
			        			<td>
			        				<input type="password" id="txtRetyprPassword" name="txtRetyprPassword" size="40" />
			        			</td>
			        		</tr>
			        		
			        	</table>
			        	</fieldset>
			        	<!-- Account Information Ends -->
			        	
			        	<div style="height: 10px;">&nbsp;</div>
			        	
			        	<!-- Account Information Starts -->
			        	<fieldset>
			        		<legend>Communication Information</legend>
			        	<table>
			        		<tr>
			        			<td width="120">Mobile No<span style="color: #F00">*</span>:</td>
			        			<td>
			        				<input type="text" id="txtMobNumber" name="txtMobNumber" size="40" />
			        			</td>
			        		</tr>
			        		<tr>
			        			<td>Email Address<span style="color: #F00">*</span>:</td>
			        			<td>
			        				<input type="text" id="txtEmailId" name="txtEmailId" size="40" />
			        			</td>
			        		</tr>
			        		
			        	</table>
			        	</fieldset>
			        	<!-- Account Information Ends -->
			        	</div>
			        </td>
			    </tr>
			    <tr>
			    	<td colspan="2" align="center">
			    		<input type="button" value="Register >>" id="btnRegister" name="btnRegister" />
			    		<input type="reset" value="Reset >>" id="btnReset" name="btnReset" />
			    	</td>
			    </tr>
			     <tr>
			    	<td colspan="2" align="center">
			    		&nbsp;
			    	</td>
			    </tr>
			</table>			
			</form>
		</p>	
	</div>
</td>
</tr>
</table>
<!-- Login Area Ends -->
</div>

<?php 
  include_once '../common/footer.php';
?>